CAVU Psychiatry | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Bipolar Substance use Trauma Insomnia/Sleep Difficulties Other

Current and Past Medications:

Limited to 600 characters

Billing & Payment

If you plan to use insurance, please enter the name of your insurance plan (for example: Aetna, Blue Cross of Idaho, Regence, Select Health, Medicare, or Medicaid)

Limited to 600 characters

Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Do you consent to the use of a documentation technology during your appointments?

Your provider may use a secure documentation assistant to help create accurate and timely notes from your appointments. This technology may include AI-assisted documentation. Your provider reviews all documentation and remains responsible for your diagnosis, treatment, medications, and clinical decisions. Your health information is protected in accordance with applicable privacy requirements, including HIPAA. You may withdraw your consent at any time without affecting your ability to receive care.

Yes No

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.